Review Article pissn / eissn J Korean Soc Radiol 2017;76(1):1-9 Uterine Artery Embolizati

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1 Review Article pissn / eissn J Korean Soc Radiol 2017;76(1):1-9 Uterine Artery Embolization: The Interventional Treatment of Female Genital Diseases 자궁동맥색전술 : 여성생식기질환의인터벤션치료 Woong Hee Lee, MD 1, Seung Boo Yang, MD 2 *, Dong Erk Goo, MD 3, Yong Jae Kim, MD 3, Jae Myeong Lee, MD 4, Chae Hoon Kang, MD 5, Joon Young Ohm, MD 6, Young Jun Kim, MD 7 1 Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, Korea 2 Department of Radiology, Soonchunhyang University Gumi Hospital, Gumi, Korea 3 Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea 4 Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea 5 Department of Radiology, Gangneung Asan Hospital, Gangneung, Korea 6 Department of Radiology, Chungnam National University College of Medicine, Chungnam National University Hospital, Daejeon, Korea 7 Department of Radiology, Presbyterian Medical Center, Jeonju, Korea The uterus is the major female sex organ and is essential for pregnancy. The organ is located in the pelvic cavity. It is usually fist-sized with its volume changing from 75 to 200 cc depending on the menstrual cycle. There are various diseases associated with the uterus, including malignancy, uterine myoma, postpartum hemorrhage, and vascular malformation. The conventional surgical treatment for these diseases is hysterectomy. However, hysterectomy has some risk, and there may be complications associated with the surgery and anesthesia. In addition, hysterectomy results in loss of fertility and loss of female characteristics, both of which may lead to emotional problems. After uterine artery embolization (UAE) was performed for post-partum bleeding in 1979 and for uterine myoma in 1995, interventional treatment of UAE replaced the existing surgical treatment of hysterectomy. UAE is performed widely as a minimally invasive treatment modality that can preserve the uterus, make pregnancy and childbirth possible and resolve emotional problems. The interventional treatment has become increasingly popular to treat various female genital diseases. Index terms Radiology, Interventional Uterine Artery Embolizations Female Genital Diseases Received March 31, 2016 Revised August 8, 2016 Accepted October 1, 2016 *Corresponding author: Seung Boo Yang, MD Department of Radiology, Soonchunhyang University Gumi Hospital, 179 1gongdan-ro, Gumi 39371, Korea. Tel Fax ysbysb@sch.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 자궁동맥해부학 (Uterine Artery Anatomy) 자궁동맥은내장골동맥 (internal iliac artery) 에서분지하며내장골동맥앞분지 (anterior division) 의하둔동맥 (inferior gluteal artery) 의첫번째분지인경우가가장많고간혹두번째, 세번째분지혹은하둔동맥및상둔동맥 (superior gluteal artery) 과삼분지 (trifurcation) 하는경우가있다. 자궁동맥은기시부에서골반의측벽을따라밑으로주행 (desceding branch) 하다가방향을바꿔중앙을향해수평방향으로주행 (transverse branch) 하며경질동맥 (cervicovaginal artery) 을낸이후에자궁의측면을따라위쪽으로주행 (ascending branch) 하며 많은관통동맥분지 (perforating branch) 들을내고이동맥분지들이자궁내에서서로연결된다. 자궁근종 (Uterine Myoma) 자궁근종은 40 세이상여성의약 20~50% 정도에서발생하는가장흔한종양이다 (1, 2). 자궁근종을가진절반정도의환자에서는특별한증상을유발하지않기때문에별다른치료가필요하지는않는다. 그러나나머지절반정도의환자에서자궁근종은비정상적인출혈, 골반통, 골반부불편감등의증상을보일수있다. 특히재발성비정상적출혈, 빈혈, 종괴압박에 Copyrights 2017 The Korean Society of Radiology 1

2 자궁동맥색전술 의한골반부통증및불편감, 비뇨기계압박에의한빈뇨, 재발성방광염, 수신증 (hydronephrosis) 등의증상을보이는경우에는적극적인치료가필요하게된다 (3). 생식샘자극호르몬분비호르몬작용제 (GnRH-agonist) 등의내과적인호르몬치료가자궁근종과관련된증상을감소시키거나소실시키는우선적치료로시행되고있으나질건조증, 두통, 우울증, 골다공증등의부작용과더불어보통 6개월이상장기간사용하지못하는단점이있다. 따라서근종절제술이나자궁적출술등수술적치료가부가적으로시행되기도한다 (4, 5). 그러나복강경근종절제술 (laparoscopic myomectomy) 은약 27% 정도에서재발하며전신마취와개복에따른위험이있다 (6). 자궁적출술은자궁을보존하지않는근치적수술로마취나수술로인한위험뿐아니라불임과여성의성상실등의결과를가져올수있다. 자궁동맥색전술은 1970 년대부터산후출혈치료에이용되었다 년 Ravina 등 (7) 이내과적치료에실패한증상을갖는다수의자궁근종환자에서자궁동맥색전술을시행하여증상호전을보였다고처음보고하였다. 그후수술적치료보다낮은 (1% 미만 ) 시술관련합병증과짧은입원기간이라는장점으로인해월경과다, 골반통, 압박증상 (pressure symptom) 등의증상을갖는자궁근종의치료방법으로인정받았으며, 기존의수술적치료를대체하는치료방법으로널리이용되고있다 (Fig. 1)(8-12). Catheter Femoral artery Fig. 1. Diagram of uterine artery embolization. 전형적인자궁근종은경계가뚜렷한종괴로 T2 강조영상에서 자궁내막과비교해저신호로 T1 강조영상에서등신호로보이 며, T2 강조영상에서고신호의변연부 (rim) 를동반할수있다. 그러나변성 (degeneration) 을보일경우불규칙한조영증강과 함께불균질한 (heterogenous) 신호를보인다. 시술후근종이 완전괴사된경우 T1 강조영상에서 hemorrhagic infarction 으 로인한고신호를, T2 강조영상에서저신호를나타내며, 조영 증강되지않는다. 또한 MRI 는시술전후근종의크기변화를 객관적으로측정할수있으며조영증강여부로근종의재발을 조기에알수있는장점등으로시술전후검사로서가장좋은 방법으로인정받고있다 (Fig. 2A, B)(14, 15). 자궁근종색전술의기전자궁동맥을차단함으로써자궁동맥으로부터혈액공급을받는근종의혈류를차단하여근종허혈에이은출혈성경색과유리질변성 (hyaline degeneration) 을유도하고, 이로인한근종체적감소로월경통, 골반통, 주변장기압박등다양한증상이호전을보이게된다. 이러한근종의허혈, 경색및변성과이로인한근종체적감소는시술직후부터시작되어수개월에걸쳐진행되며길게는수년에걸쳐이루어진다고알려져있다. 일반적으로시술 3개월후자궁근종체적이 44% 로가장많이감소하는것으로알려져있으며, 그이후에도점진적으로감소되어 5년까지는잘재발하지않는것으로보고되었다 (8, 13). 색전술대상환자의선별및시술전후검사출혈, 압밥증상, 빈혈, 골반부통증을갖는자궁근종은색전술의적응증이되며이의진단에는일반적으로초음파가일차적으로사용되어근종의위치, 크기, 개수등을확인한다. 그러나근종의크기가큰경우초음파의사용이제한적일수밖에없다. 반면자궁부속기질환의유무, 자궁내막암이나경부암등과의감별을위해서는 MRI 가매우유용한정보를제공한다. 시술일반적인동맥색전술과유사하게, 편측의대퇴동맥을천자하여 4~5 Fr 카테터로양측의내장골동맥을선택한후혈관손상이나혈관수축등을방지하기위하여 3 Fr 미만의미세카테터로양측자궁동맥을초선택한다. 주입한조영제가 5~10 번의심장박동동안정체될정도로색전물질을주입한다. 동측의내장골동맥을선택할때는왈트만루프테크닉 (Waltman loop technique) 을이용하여용이하게시술할수있으며난소동맥의확인이필요한경우에는 flush pelvic arteriogram 을시행할수있다. 색전물질의주입시미세카테더의끝을경질동맥너머상행분절 (ascending segment) 에위치시키는것이자궁괴사나경질신경총 (cervicovaginal plexus) 의손상에따른성기능장애를방지하는데도움이된다. 색전물질로는 polyvinyl alcohol ( 이하 PVA) particle, trisacryl gelatin microsphre (Embosphre), gelfoam 등이사용된다. PVA 는가장널리사용되는색전물질로 355 미크론이하의 PVA particle 은심한통증과난소동맥의색전으로인한난소기능저하를초래할수있어통상 355~700 미크론의큰입자가주로사용된다. Embosphere 는 trisacryl 을젤라틴과교차결합시킨것으로응집 (clumping) 되지않아미세카 2 대한영상의학회지 2017;76(1):1-9 jksronline.org

이웅희외 A B C D Fig. 2. Uterine fibroid. A, B. Pre-procedural MRI on T2-weighted sagittal image (A) and gadolinium enhanced T1-weighted image (B).

Left internal iliac arteriogram shows marked hypertrophy of left uterine artery and increased vascularity. D.

합병증자궁근종색전술후발생하는합병증은골반부통증이가장흔하다 (17, 18). 이는정상자궁조직의허혈이나근종의괴사에의해서발생할수있다. 대부분의경우는 ketoprofen 등의소염진통제나 morphine, demerol 등과같은마약성진통제의근주, 혹은정맥내주사로조절할수있으나통증조절장치를시술해야하는경우도있다 (19).

자궁감염시술과관련되어혹은자궁근종의괴사에의해자궁축농증 (pyometra), 난관염 (salpingitis) 등의자궁내감염이발생할수있으며심할경우자궁적출술을요하는경우도있다 (17, 20, 21). 따라서시술전후로광범위항생제의투여가필요하며지속되는복통과고열이있을경우에는초음파, CT, MRI 등의영상검사와혈액검사를통한확인이필요하다.

3 이웅희외 A B C D Fig. 2. Uterine fibroid. A, B. Pre-procedural MRI on T2-weighted sagittal image (A) and gadolinium enhanced T1-weighted image (B). Intramutal type myoma is demonstrated in uterine fundus and body with contrast enhancement. C. Left internal iliac arteriogram shows marked hypertrophy of left uterine artery and increased vascularity. D. Following embolization with polyvinyl alcohol particles, left uterine arteries are occluded. 테터와혈관에쉽게주입되는특징이있다. 처음에는신경중재술영역에서고위험색전술용으로개발되었다가현재는자궁근종색전술에매우효과적인것으로알려져널리쓰인다 (Fig. 2C, D)(16). 합병증자궁근종색전술후발생하는합병증은골반부통증이가장흔하다 (17, 18). 이는정상자궁조직의허혈이나근종의괴사에의해서발생할수있다. 대부분의경우는 ketoprofen 등의소염진통제나 morphine, demerol 등과같은마약성진통제의근주, 혹은정맥내주사로조절할수있으나통증조절장치를시술해야하는경우도있다 (19). 그러나매우극심한통증은보통시술후 24 시간이후에는잘발생하지않으므로환자에대한정신적지지도매우중요하다. 그외발생하는대부분의합병증은혈관천자와관련한혈종, 동맥박리, 동정맥루, 천자부위의감염및조영제에의한알러지반응등이다. 반면드물지만발생하면심각한문제를일으킬수있는합병증도있으며아래와같다. 자궁감염시술과관련되어혹은자궁근종의괴사에의해자궁축농증 (pyometra), 난관염 (salpingitis) 등의자궁내감염이발생할수있으며심할경우자궁적출술을요하는경우도있다 (17, 20, 21). 따라서시술전후로광범위항생제의투여가필요하며지속되는복통과고열이있을경우에는초음파, CT, MRI 등의영상검사와혈액검사를통한확인이필요하다. 난소기능부전자궁근종색전술후 2~7% 에서난소기능부전으로인한조기폐경이발생하며대체로 45 세이상에서흔하다. 색전술시의도하지않은색전물질의난소유입으로인한기능부전이온다는의견과난소기능에영향을미치는호르몬을분비하는자궁자체에대한색전으로기능저하를초래한다는견해등이있으나아직도원인은명확하지않다 (22, 23). Razavi 등 (24) 은자궁근종환자들의혈관조영술소견상자궁동맥과난소동맥간의세가지문합형태를제시하였으며, 그중 Ib형과 III 형은자궁동맥색전술시원치않는난소의색전을유발할수있는문합의형태라고하였다. 따라서혈관조영술상자궁-난소동맥문합부위를통한난소로의역류가보이는경우에는비표적색전을피하기위하여색전술전코일을이용하여문합부위를차단함으로써원치않는난소의색전을피하는것이조기폐경의가능성을줄이는데도움이될것이다 (25). 자궁근종의질외배출 (Fibroid Expulsion) 대부분점막하근종 (submucosal myoma) 에서그리고드물게는벽내근종 (intramural myoma) 의경우에괴사된근종이자궁밖으로배출될수있다. 배출되면서심한통증이나출혈이발생되지않은경우는합병증이라기보다는좋은시술결과로볼수있다. 그러나배출도중심한출혈이나자궁의허혈성손상에의한심한통증이지속되는경우에는적극적인치료가필요하며경우에따라서는자궁적출술이필요할수도있다 (26-28). 자궁근종색전술의치료효과판정및예측일반적으로자궁근종색전술후과다월경증은 83~90%, 생 jksronline.org 대한영상의학회지 2017;76(1):1-9 3

4 자궁동맥색전술 리통은 77~79%, 종괴효과에의한증상은 86~93% 에서개선되고시술만족도는 91~97% 에달하는것으로보고된다. 또한자궁근종색전술후근종체적은 42~73%, 자궁자체는 33~ 55% 로감소되며이러한체적감소는시술후 5년까지진행하는것으로되어있다 (8, 29). 치료효과예측에대해서도많은연구보고들이있다. Spies 등 (30) 은자궁근종의성공적인치료와관련한인자에대한연구에서, 근종의위치가벽내혹은장막하보다점막하에위치하거나근종체적이작은경우체적감소율이더높아, 위치나체적인자로치료효과를예측할수있다고하였다. 통상 10 cm 이상의근종과장막하근종은감염혹은재발등의이유로근종색전술이효과적이지않다고보고하고있으나 (31, 32), 최근의연구에서는장막하근종이나크기가큰근종에서도치료효과가좋다는보고들이있어이에대한연구는더필요하리라생각된다 (33). 그외시술전시행한색도플러초음파나조영증강 MRI 에서과혈관정도가근종체적감소에의한시술성공을예측할수있다는보고가있다 (34, 35). 반면 Weintraub 등 (36) 은혈류정도가시술성공여부를예측하는인자로보기에는곤란하다고보고하여이에대한연구도필요하리라생각된다. Yang 등 (37) 은색전술시행후촬영한비조영증강골반 CT 상측정한 CT계수가 80 Hounsfield unit 이상인경우체적감소효과가우수하였으며조기에색전술의치료효과를알수있었다고보고함으로써시술후골반부 CT 촬영만으로도조기에색전술의성공여부를예측할수있을것으로생각된다. 자궁근종색전술이생리와임신에미치는영향생리와임신에대한색전술의영향은아직분명하지않으나자궁근종색전술후에많은경우에서성공적인임신을보고하고있다 (38, 39). Tropeano 등 (38) 은 40세이하의여성에서자궁근종색전술후난소보유능 (ovarian reserve) 에뚜렷한변화가없다고보고하여생리등에영향을미치지않을것이라고하였다. 하지만이에대해서도앞으로많은연구가필요하리라생각된다. 산후출혈 (Postpartum Hemorrhage) 분만후출혈은모성사망의중요한원인중하나이다. 분만후 24 시간내에 500 cc 이상의대량출혈이있는경우나, 분만후적혈구용적 (hematocrit) 이입원시보다 10% 이상감소가있는경우로, 24 시간이내의출혈은조기혹은일차성산후출혈이라고하고, 24 시간이후에서 6주사이의출혈은지연출혈이라고한다 (40-42). 산후출혈의원인으로는자궁무력증, 산도열 상, 혈액응고장애, 잔류태반등이있으며, 이중잔류태반은지 연출혈의중요한원인이다 (43, 44). 산후출혈의치료로는자궁 긴장성약물 (uterotonic drug), 열상의일차봉합, 자궁내충전 (intrauterine tamponade) 등이있으며, 출혈이지속되는경우 전신마취하에내장골동맥결찰또는자궁적출술등이시행된 다 (45, 46). 최근에경도관동맥색전술과같은덜침습적인치 료가산후출혈에있어 92~98% 의높은치료효과와함께매우 작은합병증으로인해널리이용되고있다 (47). 자궁파열이나 방광손상이의심될때는수술이선호된다. 제왕절개술후출혈 에혈관결찰을할수있으나빠른시간내에중재적시술이가 능하다면색전술이종종우선시된다 (48). 산후출혈을일으키는흔한동맥들은자궁동맥, 질동맥 (vaginal artery), 음부동맥 (pudendal artery) 및드물게난소동맥 등이있다 (49, 50). 시술방법은자궁근종의색전술과마찬가 지로자궁동맥이나출혈을일으키는동맥을미세카테터로선택 하여주로 gelfoam 또는드물게 PVA particle, 히스토아크릴또 는코일등으로색전한다. 혈관조영술상조영제의혈관밖유출 (contrast extravasation) 이보이는경우해당혈관을초선택하여 색전술을시행할수있다. 그러나대량출혈로인한저혈량일경 우혈관수축으로인해조영제의유출이보이지않게되며이경 우의심되는혈관에대하여반복적으로조영술을시행하여확 인해야한다. 또한자궁무력증에의한출혈의경우에는대부분 의경우에서자궁동맥의과혈관성 (hyperemia) 외에특별한소 견을보이지않으므로양측자궁동맥을선택적으로색전하여야 치료효과를볼수있다 (Fig. 3)(51). 자궁의혈관기형 (Uterine Vascular Malformation) 자궁의혈관기형은자궁내혹은주변에위치하는비정상적 인동정맥연결의엉킨덩어리로서간헐적인질출혈혹은사망에 이를수있는심각한출혈을일으키는질환이다. 이러한자궁의 혈관기형은, 대부분을차지하는선천성 (congenital) 혈관기형 과드문후천성혈관기형으로분류된다. 후천성혈관기형은소 파수술, 치료적유산, 기왕자궁수술, 자궁내막암, 임신성융 모성질환등에의해발생하며아주드물게는정상분만후에 발생하기도한다. 후천성자궁의혈관기형은젤폼, PVA particle 등을이용하여색전하여재발없이치료할수있으며간혹코일, 글루, 알코올등이색전물질로사용되기도한다 (Fig. 4)(52). 4 대한영상의학회지 2017;76(1):1-9 jksronline.org

이웅희외 A B Fig. 3. Angiographic findings of post-partum hemorrhage. A. Right uterine angiogram shows contrast media extravasation (arrow) from right uterine artery branch.

artery. A B C Fig. 4. Uterine vascular malformation. A. Color ultrasonogram shows turbulent flow lesion in uterine body.

Post embolization state of uterine artery with polyvinyl alcohol particle.

의경우에서자궁동맥색전술이효과적이었으며이후정상적인출산을하였다는보고가많다 (29, 53, 54).

따라서모든자궁외임신이자궁동맥색전술의적응증이되지 는않으나경부 (cervical) 혹은자궁각 (interstitial) 자궁외임신의경우자궁동맥색전술이자궁각절제술 (cornual resection)

5 이웅희외 A B Fig. 3. Angiographic findings of post-partum hemorrhage. A. Right uterine angiogram shows contrast media extravasation (arrow) from right uterine artery branch. B. Left uterine angiogram shows no definite bleeding focus, but only visible hypervascularity of the uterine artery. A B C Fig. 4. Uterine vascular malformation. A. Color ultrasonogram shows turbulent flow lesion in uterine body. B. Uterine angiogram shows a tangle of vessels in the region of uterus fed by uterine artery. C. Post embolization state of uterine artery with polyvinyl alcohol particle. 자궁외임신 (Ectopic Pregnancy) 여러연구에서경부자궁외임신 (cervical ectopy) 의경우와몇몇예의자궁각자궁외임신 (cornual ectopy) 의경우에서자궁동맥색전술이효과적이었으며이후정상적인출산을하였다는보고가많다 (29, 53, 54). 자궁경부와자궁각부위는주로자궁동맥에서혈류공급을받으며, 이혈류의차단은태반기능과태아성장에영향을미치는융모변성 (trophoblastic degeneration) 을유도하여임신을종료할수있으리라생각되고있다. 따라서모든자궁외임신이자궁동맥색전술의적응증이되지 는않으나경부 (cervical) 혹은자궁각 (interstitial) 자궁외임신의경우자궁동맥색전술이자궁각절제술 (cornual resection) 혹은자궁적출술등의수술적치료를대체하는시술로활용될수있을것으로생각된다 (Fig. 5). 기타질환의자궁동맥색전술 자궁선근증 (adenomyosis) 은이소성 (heterotopic) 자궁내막선 (endometrial gland) 과간질 (stroma) 이자궁근육층에존재하면서주위평활근의증식을일으키는질환이다. 월경과다증, jksronline.org 대한영상의학회지 2017;76(1):1-9 5

자궁동맥색전술 A B C D Fig. 5. Cornual ectopic pregnancy. A. Gestational sac was surrounded by an asymmetric myometrial mantle. B. Right uterine angiogram before embolization.

Post embolization uterine arteriogram shows occlusion of right uterine artery. D.

월경통등의증상을보이며자궁절제술이확실한치료이나자궁동맥색전술이점차시도되고있다. 색절술의효과는보고자에따라차이가있어논란의여지가있다 (55, 56). Kim 등 (57) 은 5년추적결과초기성공률 92.

진행성자궁암 (advanced uterine cancer) 이나자궁경부암 (cervical cancer) 과같은악성종양에서도근치적인치료는불가능하나조절되지않는출혈의치료를위해자궁동맥색전술을고려해볼수있다.

Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: 433-445 2.

6 자궁동맥색전술 A B C D Fig. 5. Cornual ectopic pregnancy. A. Gestational sac was surrounded by an asymmetric myometrial mantle. B. Right uterine angiogram before embolization. Increased vascularity at right uterine cornua is noted. C. Post embolization uterine arteriogram shows occlusion of right uterine artery. D. Transvaginal sonogram demonstrates collapsed gestational sac with normal endometrial stripe. 월경통등의증상을보이며자궁절제술이확실한치료이나자궁동맥색전술이점차시도되고있다. 색절술의효과는보고자에따라차이가있어논란의여지가있다 (55, 56). Kim 등 (57) 은 5년추적결과초기성공률 92.6%, 재발률 38% 의결과를보고하였고색전물질이작을수록괴사를보다많이일으켜결과에차이가있을것으로추측하였다. 위와같은결과를볼때수술이외에특별한치료방법이없음을감안하면, 재발률이적지않으나일차적치료로자궁동맥색전술을고려해볼수있을것이다. 진행성자궁암 (advanced uterine cancer) 이나자궁경부암 (cervical cancer) 과같은악성종양에서도근치적인치료는불가능하나조절되지않는출혈의치료를위해자궁동맥색전술을고려해볼수있다. 많은수의자료가있지는않으나급박한대량출혈에효과적이고수혈로인한부작용을감소시킬수있 다. 시술후흔한합병증으로조직괴사로인한심한통증이있을수있으나대부분진통제로조절이가능하다 (58). REFERENCES 1. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36: Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992;58: Itkin M, Shlansky-Goldberg R. Uterine fibroid embolization for the treatment of symptomatic leiomyomata. Appl Radiol 2002;31: Sutton CJ. Treatment of large uterine fibroids. Br J Obstet 6 대한영상의학회지 2017;76(1):1-9 jksronline.org

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8 자궁동맥색전술 garding sloughing of fibroids after uterine artery embolization. J Vasc Interv Radiol 1999;10: Berkowitz RP, Hutchins FL Jr, Worthington-Kirsch RL. Vaginal expulsion of submucosal fibroids after uterine artery embolization. A report of three cases. J Reprod Med 1999; 44: Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up. BJOG 2002;109: Spies JB, Roth AR, Jha RC, Gomez-Jorge J, Levy EB, Chang TC, et al. Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome. Radiology 2002;222: McLucas B, Adler L, Perrella R. Predictive factors for success in uterine fibroid embolization. Min Invas Ther Allied Technol 1999;8: Pelage JP, Le Dref O, Soyer P, Kardache M, Dahan H, Abitbol M, et al. Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 2000;215: Katsumori T, Nakajima K, Mihara T. Is a large fibroid a high-risk factor for uterine artery embolization? AJR Am J Roentgenol 2003;181: Fleischer AC, Donnelly EF, Campbell MG, Mazer MJ, Grippo D, Lipsitz NL. Three-dimensional color Doppler sonography before and after fibroid embolization. J Ultrasound Med 2000;19: Lipman JC, Smith SJ, Spies JB, Siskin GP, Machan LS, Bonn J, et al. IV. Uterine fibroid embolization: follow-up. Tech Vasc Interv Radiol 2002;5: Weintraub JL, Romano WJ, Kirsch MJ, Sampaleanu DM, Madrazo BL. Uterine artery embolization: sonographic imaging findings. J Ultrasound Med 2002;21: ; quiz Yang SB, Lee SJ, Choi GC, Im HH, Goo DE, Lee HK, et al. Hounsfield number neasurement after a uterine fibroid embolization: significance as a predictive factor of embolization success. J Korean Radiol Soc 2008;59: Tropeano G, Di Stasi C, Litwicka K, Romano D, Draisci G, Mancuso S. Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years. Fertil Steril 2004;81: Ravina JH, Vigneron NC, Aymard A, Le Dref O, Merland JJ. Pregnancy after embolization of uterine myoma: report of 12 cases. Fertil Steril 2000;73: Vegas G, Illescas T, Muñoz M, Pérez-Piñar A. Selective pelvic arterial embolization in the management of obstetric hemorrhage. Eur J Obstet Gynecol Reprod Biol 2006;127: Combs CA, Murphy EL, Laros RK Jr. Factors associated with hemorrhage in cesarean deliveries. Obstet Gynecol 1991; 77: Pelage JP, Soyer P, Repiquet D, Herbreteau D, Le Dref O, Houdart E, et al. Secondary postpartum hemorrhage: treatment with selective arterial embolization. Radiology 1999; 212: Shevell T, Malone FD. Management of obstetric hemorrhage. Semin Perinatol 2003;27: Deux JF, Bazot M, Le Blanche AF, Tassart M, Khalil A, Berkane N, et al. Is selective embolization of uterine arteries a safe alternative to hysterectomy in patients with postpartum hemorrhage? AJR Am J Roentgenol 2001;177: Seror J, Allouche C, Elhaik S. Use of Sengstaken-Blakemore tube in massive postpartum hemorrhage: a series of 17 cases. Acta Obstet Gynecol Scand 2005;84: Danso D, Reginald P. Combined B-lynch suture with intrauterine balloon catheter triumphs over massive postpartum haemorrhage. BJOG 2002;109: Salomon LJ, detayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod 2003;18: Soyer P, Dohan A, Dautry R, Guerrache Y, Ricbourg A, Gayat E, et al. Transcatheter arterial embolization for postpartum hemorrhage: indications, technique, results, and complications. Cardiovasc Intervent Radiol 2015;38: Gilbert L, Porter W, Brown VA. Postpartum haemorrhage--a continuing problem. Br J Obstet Gynaecol 1987;94: Ko SF, Lin H, Ng SH, Lee TY, Wan YL. Postpartum hemorrhage with concurrent massive inferior epigastric artery bleeding after cesarean delivery. Am J Obstet Gynecol 2002;187: 대한영상의학회지 2017;76(1):1-9 jksronline.org

9 이웅희외 51. Goffinet F, Haddad B, Carbonne B, Sebban E, Papiernik E, Cabrol D. [Practical use of sulprostone in the treatment of hemorrhages during delivery]. J Gynecol Obstet Biol Reprod (Paris) 1995;24: Grivell RM, Reid KM, Mellor A. Uterine arteriovenous malformations: a review of the current literature. Obstet Gynecol Surv 2005;60: Ophir E, Singer-Jordan J, Oettinger M, Odeh M, Tendler R, Feldman Y, et al. Uterine artery embolization for management of interstitial twin ectopic pregnancy: case report. Hum Reprod 2004;19: Deruelle P, Lucot JP, Lions C, Robert Y. Management of interstitial pregnancy using selective uterine artery embolization. Obstet Gynecol 2005;106(5 Pt 2): Siskin GP, Tublin ME, Stainken BF, Dowling K, Dolen EG. Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging. AJR Am J Roentgenol 2001;177: Pelage JP, Jacob D, Fazel A, Namur J, Laurent A, Rymer R, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology 2005;234: Kim MD, Kim S, Kim NK, Lee MH, Ahn EH, Kim HJ, et al. Long-term results of uterine artery embolization for symptomatic adenomyosis. AJR Am J Roentgenol 2007;188: Samina NM, Muhammad S. Role of uterine artery embolization in the management of cervical cancer: review article. J Cancer Sci Ther 2012;4: 자궁동맥색전술 : 여성생식기질환의인터벤션치료 이웅희 1 양승부 2 * 구동억 3 김용재 3 이재명 4 강채훈 5 엄준영 6 김영준 7 여성생식기인자궁은출산에필수적일뿐아니라여성의성을상징하는대표적인장기이다. 자궁은보통주먹만한크기로생리주기에따라 75~200 cc로체적이변하며골반강내에위치한다. 자궁과관련되어서많은질환이발생할수있으며악성종양뿐아니라자궁근종 (uterine myoma), 산후출혈 (postpartum hemorrhage), 혈관기형 (vascular malformation), 자궁외임신 (ectopic pregnancy) 등의질환이발생한다. 이러한질환의치료로이전에는대부분자궁적출술등의고식적인치료를하였다, 그러나외과적수술은마취및수술과정에따른위험과부작용을가지고있을뿐아니라출산능력상실과여성의성상실이라는정서적문제를가지고있다 년산후출혈치료에그리고 1995 년자궁근종치료에자궁동맥색전술 (uterine artery embolization) 이시행된이후자궁동맥색전술과같은중재적치료방법 (interventional treatment) 이자궁질환과관련된수술을대체하여자궁을보존하여임신및출산을가능하게하고정서적문제를해결할수있는최소침습적인치료로널리시행되고있다. 이러한중재적시술은현재여러여성생식기질환에유용하게사용되고점차증가하는추세이다. 1 순천향대학교천안병원영상의학과, 2 순천향대학교구미병원영상의학과, 3 순천향대학교서울병원영상의학과, 4 순천향대학교부천병원영상의학과, 5 강릉아산병원영상의학과, 6 충남대학교의과대학충남대학교병원영상의학과, 7 전주예수병원영상의학과 jksronline.org 대한영상의학회지 2017;76(1):1-9 9

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¾ç½ÂºÎ 229 A B C D Fig. 1. Intramural type uterine myoma in a 32-year-old woman presented with hypermenorrhea and vaginal bleeding. A. Left uterine artery angiogram shows collateral vessel(arrow) to the the left